Background: Trauma is an increasing cause of morbidity and mortality in India. Blunt injury to the abdomen frequently results in life-threatening splenic injuries. Materials and Methods: This was a retrospective observational study of all patients more than 18 years old presenting to our emergency department with blunt abdominal trauma resulting in a splenic injury between 2006 and 2011. Details of the incident, injuries, and outcome were noted. Results: During the study of 2006–2011, 51 patients with splenic injury following blunt trauma to the abdomen were enrolled. There was a significant male predominance (94.1%). Road traffic accident (RTA) was the predominant mode of injury (66.7%) followed by fall from height (25.5%). On examination, the majority of the patients (82.4%) had abdominal tenderness while abdominal distension and guarding were seen in 60.8% and 31.4% of patients, respectively. A third (35.3%) of the patients was hypotensive at presentation. All the patients were started on crystalloids while blood products were transfused in 70.6% of the patients. Splenic injury was diagnosed during the primary survey in 92% of the patients. Emergency department (ED) physicians diagnosed free fluid and solid organ injuries on focused abdominal sonography in trauma (FAST) in 80.4% and 47.1% of patients, respectively. Computed tomography scan of the abdomen was performed in 57% of the patients. More than half (58.8%) were managed conservatively. The mortality rate was 10%. Conclusions: RTAs are the most common cause of splenic injury. ED physicians are quite reliable in diagnosing free fluid in the abdomen with FAST. Aggressive fluid resuscitation with blood products is the key to survival in both conservatively and surgically managed patients.

Keywords: Blunt trauma abdomen, emergency department, spleen, trauma

How to cite this article:Abhilash KP, Kirubairaj MA, Meenavarthini K. Splenic injuries in blunt trauma of the abdomen presenting to the emergency department of a large tertiary care hospital in South India. Curr Med Issues 2017;15:278-81

How to cite this URL:Abhilash KP, Kirubairaj MA, Meenavarthini K. Splenic injuries in blunt trauma of the abdomen presenting to the emergency department of a large tertiary care hospital in South India. Curr Med Issues [serial online] 2017 [cited 2019 Mar 21];15:278-81. Available from: http://www.cmijournal.org/text.asp?2017/15/4/278/218638

Introduction

With economic growth, industrialization and rapid growth of automobile industries, the number of road traffic accidents (RTA) is sharply on the rise in developing countries like India. The abdomen is a very vulnerable site with many vital organs, and abdominal injuries are often life-threatening. Blunt trauma abdomen accounts for approximately 79% of all abdominal injuries.[1],[2],[3] The spleen and liver are the most commonly injured intra-abdominal organs following blunt trauma.[4],[5],[6] In up to 60% of patients, the spleen is the only organ injured, with a mortality rate of roughly 8.5%.[2],[3],[4] Over 75% of splenic injuries occur due to motor vehicle collisions.

The spleen is the most vascular organ of the body, and approximately 350 liters of blood passes through it per day. It is located posterolaterally in the left upper quadrant of the abdomen beneath the left hemidiaphragm and lateral to the greater curvature of the stomach. Splenic injuries, therefore, result in a potentially life-threatening situation in patients with thoracoabdominal trauma. The spectrum of injuries range from the trivial to the catastrophic and hence the initial assessment, resuscitation, and investigation of patients with abdominal trauma must be individualized. Abdominal distension, left hypochondrial tenderness, tachycardia, and hypotension are the usual signs of splenic injury. The primary goal is prompt diagnosis and aggressive management of potentially life-threatening hemorrhage. The preservation of functional splenic tissue is secondary and in selected patients may be accomplished using non-operative management or operative salvage techniques. Emergent and urgent splenectomy remains a life-saving measure for many patients. The outcome of conservative management of splenic injuries remains unpredictable because of the risk of a delayed splenic rupture despite the initial computed tomography (CT) scan showing only a minor parenchymal injury.[7],[8],[9] Our aim is to study the profile of splenic injuries following blunt abdominal trauma among patients presenting to the emergency department (ED).

Materials and Methods

The study was conducted at the ED of Christian Medical College, Vellore from January 2006 to December 2011. This is a 2700 bedded tertiary care center in the South of India that receives patients from all parts of India and South East Asia. The ED is a 45 bedded emergency with a triage-based priority system which receives an average of 190–240 patients a day. Among the individuals admitted with trauma, about 12%–15% of the cases and are managed in the resuscitation room and trauma bay, which is an area that is specifically allocated for management of trauma. The study was a retrospective, cohort study of patients presenting to the adult ED with splenic injury due to trauma. Pediatric trauma cases were excluded. The main objectives were to study the mode of injury, associated injuries, and the outcome from the ED. Data were obtained from the electronic hospital records. Details of history and physical examination findings of all patients were recorded on a standard data collection sheet. The following were extracted: demographics, mode of injury, severity of injury, type of injury, presence of other injuries, and proportion of patients undergoing operative intervention. All patients had routine blood investigations and relevant radiological tests based on the initial primary and secondary surveys. After initial stabilization by the ED team, the patients were handed over to the surgical department for further management.

Statistical analysis was performed using SPSS software version 16.0. Mean (standard deviation) or median (range) were calculated for the continuous variables and t-test or Mann–Whitney test was used to test the significance. The categorical variables were expressed in proportion. This study was approved by the Institutional Review Board and patient confidentiality was maintained using unique identifiers and by password protected data entry software with restricted users.

Results

During the study, a total of 51 patients were included in the analysis. There was a significant male predominance (94.1%). RTA was the predominant mode of injury (66.7%) followed by fall from height (25.5%). Among the RTAs, 2 wheelers were involved in one-third of cases. The baseline characteristics are shown in [Table 1]. On examination, majority of the patients (82.4%) had abdominal tenderness while abdominal distension and guarding were seen in 60.8% and 31.4% of patients, respectively. Packed cell volume was <20% in 5.9% (3 patients), 20%–30% in 31.4% (19 patients), 30%–40% in 54.9% (28 patients), and >40% in 7.8% (4 patients). A third (35.3%) of the patients were hypotensive at presentation. The clinical examination findings and associated injuries are shown in [Table 2]. All the patients were started on crystalloids while blood products were transfused in 70.6% of the patients. Focused abdominal sonography in trauma (FAST) was performed by both the ED physicians and the on-call radiologists. The pickup rate of positive findings comparing the ED physicians and radiologists is shown in [Table 3]. ED physician reported free fluid in 41 patients (80.4%) and solid organ injury in 24 patients (47.1%). Radiologists reported free fluid in 43 patients (84.3%) and solid organ injury in 40 patients (78.4%). Splenic injury was diagnosed during the primary survey in 92% of the patients. CT scan of the abdomen was performed in 57% of the patients. More than half (58.8%) were managed conservatively. The duration of ED stay, patient disposition and outcome are shown in [Table 4]. Half the patients (51%) were either admitted or shifted to the operation theater with 12 h of ED admission. The mortality rate was 10%.

Management of blunt trauma of the abdomen is a challenging task even in the best trauma centers with the best traumatologists. In many cases, clinical evaluation of blunt abdominal injuries may be masked by other more obvious external injuries such as head injury or an open extremity injury, and hence diagnosis is frequently delayed. Unrecognized abdominal injury is a frequent cause of preventable death after trauma.[10] Our study studied the profile and outcome of patients with splenic injury in one of the most advanced tertiary care hospitals of India.

Early diagnosis and prompt management of potentially life-threatening hemorrhage are of paramount importance. Suspicion for splenic injury arises when the patient has left upper quadrant tenderness or left-sided chest trauma. The evaluation of splenic injury may be done by ultrasonography (FAST) or CT scan.[11],[12] FAST is a rapid bedside test that is very useful in hemodynamically unstable patients; however, a negative FAST examination does not necessarily rule out a splenic injury.[13] Ultrasonography offers the advantage of no radiation exposure and no requirement of contrast but is limited by the fact that it is highly operator dependent. CT scan of the abdomen probably yields maximum information, but its routine use is hindered by the risk of radiation exposure and allergic reactions and nephrotoxic risks due to contrast. Assessment and management of patients with blunt abdominal trauma remain a challenge for the emergency physicians. In our study, all the FAST findings of by the ED physicians were confirmed by the radiologists. This indicated that the ED physicians were competent at diagnosing free fluid in the abdomen with appropriate training. However, the pickup rate for solid organ injuries by the ED physicians was quite low and required the expertise of radiologists.

At presentation, 35.3% of our patients had hypotension. Two-thirds of the patients needed blood transfusion during initial management of shock. Blood transfusion along with crystalloids is the key in the early management of splenic injured patients. Blood products are a rare commodity in many parts of India due to a shortage of certified blood banks and most hospitals expect major trauma centers do not have immediate access to the blood bank.[14] Resuscitation in a patient with significant splenic injury without blood products could be fruitless. Many primary and secondary health centers lack certain essential facilities such as CT scan, blood bank, and operating theaters for evaluating and treating severe cases of trauma. Trauma centers with immediate access to blood banks are the need of the hour in a developing country like India.

Although a male predominance among trauma victims is seen in most international studies, the sex ratio in our study was very heavily skewed toward males.[15],[16] This is explained by the fact that in our country, males are predominantly engaged in outdoor activities and operation of automobiles and hence are more vulnerable to injuries. Polytrauma victims refer to those individuals with multiple traumatic injuries. In our study, most of the patients had other associated injuries, mostly extremity and head injuries. Among the internal organs in the abdomen, spleen due to its high vascularity remains one of the most vulnerable organs.

More than half the patients in our study were managed conservatively. Evidence of splenic injury (laceration in 19 patients and hematoma in 11 patients) were confirmed peroperatively. All those patients managed conservatively were admitted and were discharged alive. Only 2 of these patients required surgical interventions which were both successful. The mortality rate (10%) seen in our study is comparable with studies from other hospitals.[4],[7],[8]

A limitation of our study was that it was conducted at a single medical center and hence the patient population may be biased by patient selection and referral pattern. Another major limitation is the retrospective nature resulting in missing charts and incomplete data.

Conclusions

Our study showed that RTAs are still the most common cause of splenic injury. ED physicians are quite reliable in diagnosing free fluid in the abdomen with FAST. Aggressive fluid resuscitation with blood products is the key to survival in both conservatively and surgically managed patients.